Journal of Cerebrovascular and Endovascular Neurosurgery

pISSN 2234-8565, eISSN 2287-3139, https://doi.org/10.7461/jcen.2019.21.4.193 Original Article

A new definition for wide-necked cerebral aneurysms

Hyun Seok Park1, Soon Chan Kwon2, Eun Suk Park2, Jun Bum Park2, Min Soo Kim2
1
Department of Neurosurgery, Dong Kang Medical Center, Ulsan, Korea,
2
Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea

J Cerebrovasc Endovasc Neurosurg.

Background : Endovascular management of wide-necked aneurysms often 2019 December;21(4):193-198
requires assisted-techniques with adjunctive devices. Wide-necked aneurysm Received : 5 September 2018
Revised : 6 January 2020
can be defined with a dome-to-neck ratio or aspect ratio; however, clinical
Accepted : 10 January 2020
definitions of wide-necked aneurysms vary. This study aimed to determine the
Correspondence to Soon Chan Kwon
most useful definition of wide-necked aneurysm to predict the need for an ad- Department of Neurosurgery, Ulsan University Hospital,
junctive device. University of Ulsan College of Medicine, Ulsan, Korea

Methods : Among 552 cases of aneurysms, 343 (62.1%) and 209 (37.9%) cas- Tel : + 082-52-250-7139
E-mail : nskwon.sc@gmail.com
es of unruptured and ruptured aneurysms, respectively, were treated in a single ORCID : http://orcid.org/0000-0003-4885-1456
institution. For each aneurysm, the (1) dome-to-neck ratio, (2) aspect ratio, and
(3) K-ratio (defined as [dome height + maximum dome width]/[2 × maximum
neck width]) were measured. We statistically analyzed patient data to deter-
mine which of the three ratios was most predictive of the need for adjunctive
devices.
Results : Among 552 cases of aneurysms, 277 (50.2%) and 275 (49.8%) cases
were treated with and without adjunctive techniques, respectively. The mean
dome-to-neck ratio, aspect ratio, and K-ratio were 1.17±0.39, 1.58±0.61, and
1.37±0.47, respectively. The K-ratio was the strongest predictor of the use of
adjunctive devices (P<0.001), and 1.3 was the most appropriate K-ratio cut-off
value (sensitivity, 72.9%; specificity, 63.6%).
Conclusions : K-ratio was the most useful predictor of the need for adjunctive
devices in the treatment of endovascular aneurysms. These results suggest
that the K-ratio may be used to define wide-necked aneurysms requiring com-
plicated management via adjunctive devices.
This is an Open Access article distributed under the
terms of the Creative Commons Attribution Non-
Commercial License (http://creativecommons.org/
Keywords Intracranial aneurysm, Endovascular treatment, Wide-necked aneurysm, licenses/by-nc/3.0) which permits unrestricted non-
commercial use, distribution, and reproduction in any
Definition medium, provided the original work is properly cited.

INTRODUCTION stents and balloons.3)5)6)8)9)12) Therefore, when planning

The standard treatment for cerebral aneurysms is
endovascular repair. However, the treatment of wide-
necked aneurysms still presents challenges owing to the
risks of coil protrusion into the parent artery and re-
currence.4)13) Endovascular embolization of these wide-
necked aneurysms increases the frequency and neces-
sity of techniques involving adjunctive devices such as
the treatment of wide-necked aneurysms, preparations
such as premedication and peri-aneurysmal vascular
profiling are required for the smooth use of adjunctive
devices and the prevention of procedure-related com-
plications.1)14) However, wide-necked aneurysms have
been defined using many indices, such as neck width,
dome-to-neck ratio, and aspect ratio, which may result
in confusion when used in clinical practice. Therefore,

Volume 21 · Number 4· December 2019 193

DEFINITION OF WIDE-NECKED CEREBRAL ANEURYSMS
to predict whether assisted techniques are required,
another index for wide-necked aneurysms is necessary.
The aim of this study was to establish a practical defini-
tion of wide-necked aneurysm that can predict the use
of adjunctive devices.
MATERIALS AND METHODS
Patients and aneurysms
Between January 2012 and December 2016, endo-
vascular treatments with coil embolization were per-
formed for 552 cerebral aneurysms in 526 patients in
a single institution. After approval by the Institutional
Review Board (IRB) of our institution (approval No.
2018001), medical records and radiologic images were
retrospectively reviewed. Based on medical records, the
aneurysms were divided into ruptured (n=209, 37.9%)
or unruptured aneurysms (n=343, 62.1%). Based on
radiologic imaging, the measurements and calculations
of the morphology of the aneurysms were performed
on two- or three-dimensional rotational angiography.
Finally, the (1) dome-to-neck ratio (maximum dome
width/maximum neck width) and (2) aspect ratio (dome
height/maximum neck width) were calculated to mea-
sure the neck size of the aneurysms. We also calculat-
ed a new reference value, termed (3) K-ratio, ([dome
height + maximum dome width]/[2 × maximum neck
width]) in order to consider both the dome height and
width of the aneurysm (Fig. 1).
Fig. 1. Definitions of wide-necked cerebral aneurysm.
194 J Cerebrovasc Endovasc Neurosurg
Coiling procedures
Patients with an unruptured aneurysm received anti-
platelet premedication (100 mg aspirin and 75 mg clopi-
dogrel) each day for at least 7 days, and patients with a
ruptured aneurysm received a loading dose of antiplate-
let medication (100 mg aspirin and 300 mg clopidogrel)
immediately after the dome was covered with the coil.
All procedures were performed by a single surgeon
under general anesthesia with systemic intravenous
heparinization. Activated clotting time was obtained
at baseline and hourly thereafter. Four types of stents
(Neuroform stent [Stryker Neurovascular, Kalamazoo,
Michigan, USA], Enterprise stent [Codman & Shurtleff,
Raynham, Massachusetts, USA], Solitaire stent (Solitaire
AB neurovascular remodeling device; Covidien, Irvine,
California, USA), and Low-profile Visualized Intralu-
minal Support stent (MicroVention, Tustin, California,
USA]) and three types of balloons (Scepter XC [Micro-
Vention], Hyperform, and Hyperglide [ev3/Covidien])
were used. The use of an adjunctive device was either
planned before the procedure, or applied when needed
during the procedure.
Radiographic and clinical outcomes
Immediate occlusion results were graded using the
Raymond grading system as complete occlusion (Grade
I), residual neck (Grade II), and residual aneurysm
(Grade III).13) Procedure-related complications included
thromboembolic infarction, aneurysm perforation, and
parent artery dissection.
Statistical analysis
Statistical analysis was performed using SPSS software
for Windows (version 19.0 [IBM Corp., Armonk, NY,
USA]) and R package (version 3.2.5, R Foundation for
Statistical Computing, Vienna, Austria). Continuous
variables are expressed as the mean and standard devia-
tion (SD), and categorical variables are expressed as the
frequency and percentage.
Multivariable logistic regression with a forward step-
wise method was used to calculate the odds ratio (OR)

with 95% confidence interval (CI). The threshold for
statistical significance was set to P<0.05.
Receiver operating characteristic (ROC) curves were
used to determine the optimal cut-off values of (1)
dome-to-neck ratio, (2) aspect ratio, and (3) K-ratio to
predict the need for an adjunctive device. The pROC
software package was used to draw ROC curves and to
calculate the area under the curve (AUC) and 95% CI.
The Youden index was used to determine optimal cut-
off values.
RESULTS
Demographic and aneurysmal characteristics
In total, 506 (91.7%) and 46 aneurysms (8.3%) arose
from the anterior and posterior circulation, respectively.
The mean aneurysmal height was 5.54±3.74 mm (range,
1.63–34.4 mm), aneurysmal width was 4.10±2.88 mm
(range, 1.3–27.7 mm), and the neck width was 3.68±1.68
mm (range, 1.32–16.1 mm).
Angiographic and clinical outcomes
All patients were treated successfully using a standard
coiling technique. The initial angiographic results re-
vealed that 424 (76.8%), 90 (16.3%), and 38 cases (6.9%)
had occlusions of Raymond grades I, II, and III, respec-
tively.
There were 28 procedure-related complications (5.1%).
Thromboembolism with neurologic deficit was doc-
umented in 10 cases (1.8%). Intraoperative aneurysm
rupture occurred in 14 (2.5%) cases, and all patients
recovered without neurologic deficits. Dissection of the
parent artery was observed in four cases (0.7%).
Table 1. Relationship of index ratios with device usage
Total
Dome-to-neck ratio 1.17±0.39
Aspect ratio 1.58±0.61
K-ratio 1.37±0.47
HYUN SEOK PARK ET AL
Relationship between ratio index and use of device
In 275 (49.8%) and 277 (50.2%) cases of aneurysms,
treatment proceeded with and without the use of an ad-
junctive device, respectively. Among the 277 cases that
required an adjunctive device, stents were used in 245
cases (88.4%), and balloons were used in 32 cases (11.6%).
In cases of ruptured and unruptured aneurysms, 40.2%
(29/69) and 73.9% (164/222) of the patients, respective-
ly, were treated with an adjunctive device.
The mean values of the dome-to-neck ratio, aspect
ratio, and K-ratio were 1.17±0.39, 1.58±0.61, and
1.37±0.47, respectively. Along with the overall values,
the mean values of these ratios for aneurysms treated
with adjunctive devices and those treated without ad-
junctive devices are shown in Table 1. Only the K-ratio
demonstrated a significant difference according to ad-
junctive device use (P<0.001). The optimal cut-off val-
ues of the dome-to-neck ratio, aspect ratio, and K-ratio
obtained using the Youden index were 1.0, 1.4, and 1.3,
respectively (Fig. 2).
Fig. 2. Reference values of the dome-to-neck ratio (1.0), aspect ratio
(1.4), and K-ratio (1.3).
Adjunctive device use
P value
Without With
1.27±0.40 1.06±0.36 0.064
1.75±0.64 1.40±0.53 0.599
1.52±0.49 1.22±0.39 <0.001
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DEFINITION OF WIDE-NECKED CEREBRAL ANEURYSMS

DISCUSSION dome-to-neck ratio or aspect ratio.

Whether or not an aneurysm has a wide neck, is an
important factor to determine the feasibility of endo-
vascular treatment. The challenge of wide-necked an-
eurysms, which are difficult to treat by simply packing
the coils into the aneurysm, can be overcome by the use
of stents and balloons. In addition, when conducting
coil embolization for the treatment of a wide-necked
aneurysm, the catheter type, size, and puncture site
should be planned in advance if the use of ancillary de-
vices, such as stents and balloons, are being considered.
Therefore, the present study investigated the index that
was most reflective of the use of adjunctive devices for
wide-necked aneurysms. Among them, we found that
the K-ratio, which incorporates both the height and
width of the aneurysm dome, was the most relevant
index of wide-necked aneurysms. This finding suggests
that the K-ratio is an appropriate indicator for judging
wide-necked aneurysms. Based on virtual models of
aneurysms (Figs. 3-4), the K-ratio appears to be more
useful for identifying wide-necked aneurysms than the
We also calculated the appropriate reference value for
this index to establish the most appropriate treatment
strategy for wide-necked aneurysms, and the K-ratio
cut-off value was set to 1.3. For K-ratios <1.3, the sen-
sitivity and specificity for the use of adjunctive devices
were 72.9% and 63.6%, respectively. The calculated cut-
off values of the dome-to-neck ratio and aspect ratio
were 1.0 and 1.4, respectively, and their sensitivities
were low (dome-to-neck ratio, 44.8%; aspect ratio,
66.4%).
Another important factor affecting the use of an ad-
junctive device was the presence of aneurysm rupture.
Among aneurysms with a K-ratio <1.3, which indicates
a wide neck, an adjunctive device was used in only
40.2% cases of ruptured aneurysms (29/69), whereas
73.9% cases of unruptured aneurysms (164/222) were
treated with an adjunctive device. This difference in the
rate of adjunctive device use was statistically significant
(P<0.001). We speculate that there are several reasons
for this result: (1) increased risk of delaying surgery
due to the necessity for anti-platelet agents prior to

A B C

Fig. 3. In cases where the maximum dome width is the neck width (cone or rod shape), (A) treatment with the coil alone may not cover the aneu-
rysm neck, or the coil is likely to protrude into the parent artery (B). In such cases, embolization with a stent will allow for successful treatment (C).

A B

Fig. 4. If the height of the aneurysm dome is small (A) but the maximum width of the dome is sufficiently larger than the neck width, the coil
alone can be used to complete the treatment (B).

196 J Cerebrovasc Endovasc Neurosurg


the use of an adjunctive device, (2) thromboembolic
complication due to insufficient premedication, and (3)
1)10)11)15)
patient burden of prolonged general anesthesia.
In summary, in cases with a K-ratio <1.3, we found that
adjunctive devices were used heavily when treating un-
ruptured aneurysms with sufficient premedication.
Using a cut-off dome-to-neck ratio <2,532 (96.4%)
aneurysms were defined as wide-necked. Meanwhile,
230 (41.6%) and 291 aneurysms (52.7%) were classified
as wide-necked when an aspect ratio <1.6 and K-ratio
<1.3 were applied as the cut-off values, respectively,
which was similar to the 277 (50.2%) cases that required
an adjunctive device. These results suggest that the
definition of wide-necked aneurysm using the dome-
to-neck ratio may require reconsideration. Brinjikji et
al.2) proposed that a dome-to-neck ratio <1.6 should be
used as the criterion for wide-necked aneurysms.
This study has several limitations. First, only patients
treated by a single surgeon were analyzed to control
for inconsistencies in criteria for adjunctive device use
across operators. This is appropriate for comparing the
relationship between the index ratios and device us-
age, but the cut-off values may differ according to the
individual surgeon’s preference for device use. There-
fore, the new ratio should be verified in other patient
populations. Second, we limited the reason for the use
of adjunctive devices to the presence of a wide neck.
Although in most cases, the neck width determines
whether an adjunctive device is needed to preserve the
parent artery, this excludes incidental causes such as
aneurysm location, vascular status, parent artery, and
dome orientation.7)
CONCLUSIONS
In this retrospective study, we established a practical
definition for wide-necked aneurysms by comparing
the association of multiple indicators with the use of
adjunctive devices in endovascular treatment. In the
present population, the K-ratio ([dome height + max-
imum dome width]/[2 × maximum neck width]) was
HYUN SEOK PARK ET AL
the most suitable definition of wide-necked aneurysm
for predicting treatment with an adjunctive device. Es-
pecially for the management of unruptured aneurysms
with a K-ratio <1.3, the use of an adjunctive device can
provide a safe and reliable treatment.
REFERENCES
  1. Bodily KD, Cloft HJ, Lanzino G, Fiorella DJ, White PM,
Kallmes DF. Stent-assisted coiling in acutely ruptured intracra-
nial aneurysms: a qualitative, systematic review of the litera-
ture. AJNR Am J Neuroradiol. 2011 Aug;32(7):1232-6.
  2. Brinjikji W, Cloft HJ, Kallmes DF. Difficult aneurysms for
endovascular treatment: overwide or undertall? AJNR Am J
Neuroradiol. 2009 Sep;30(8):1513-7.
  3. Chung J, Lim YC, Suh SH, Shim YS, Kim YB, Joo JY, et al.
Stent-assisted coil embolization of ruptured wide-necked an-
eurysms in the acute period: incidence of and risk factors for
periprocedural complications. J Neurosurg. 2014 Jul;121(1):4-
11.
  4. Cloft HJ, Joseph GJ, Tong FC, Goldstein JH, Dion JE. Use of
three-dimensional Guglielmi detachable coils in the treatment
of wide-necked cerebral aneurysms. AJNR Am J Neuroradiol.
2000 Aug;21(7):1312-4.
  5. Fischer S, Weber A, Carolus A, Drescher F, Gotz F, Weber W.
Coiling of wide-necked carotid artery aneurysms assisted by
a temporary bridging device (Comaneci): preliminary experi-
ence. J Neurointerv Surg. 2017 Nov;9(11):1039-97.
  6. Kitahara T, Hatano T, Hayase M, Hattori E, Miyakoshi A, Na-
kamura T. Jailed double-microcatheter technique following
horizontal stenting for coil embolization of intracranial wide-
necked bifurcation aneurysms: a technical report of two cases.
Interv Neuroradiol. 2017 Apr;23(2):117-22.
  7. Kiyosue H, Tanoue S, Okahara M, Hori Y, Nakamura T, Na-
gatomi H, et al. Anatomic features predictive of complete an-
eurysm occlusion can be determined with three-dimensional
digital subtraction angiography. AJNR Am J Neuroradiol. 2002
Aug;23(7):1206-13.
  8. Kuriyama T, Sakai N, Niida N, Sueoka M, Beppu M, Dahma-
ni C, et al. Dose reduction in cone-beam CT scanning for
intracranial stent deployment before coil embolization of
intracranial wide-neck aneurysms. Interv Neuroradiol. 2016
Aug;22(4):420-5.
  9. Labeyrie PE, Gory B, Aguilar-Perez M, Pomero E, Biondi A,
Riva R, et al. The pCONus device for treatment of complex
wide-neck anterior communicating artery aneurysms. World
Neurosurg. 2017 May;101:498-505.
10. Lee YJ, Kim DJ, Suh SH, Lee SK, Kim J, Kim DI. Stent-assist-
Volume 21 · Number 4· December 2019 197
DEFINITION OF WIDE-NECKED CEREBRAL ANEURYSMS
ed coil embolization of intracranial wide-necked aneurysms.
Neuroradiology. 2005 Sep;47(9):680-9.
11. Lodi YM, Latorre JG, El-Zammar Z, Swarnkar A, Deshaies E,
Fessler RD. Stent assisted coiling of the ruptured wide necked
intracranial aneurysm. J Neurointerv Surg. 2012 Jul;4(4):281-6.
12. Peterson E, Hanak B, Morton R, Osbun JW, Levitt MR, Kim
LJ. Are aneurysms treated with balloon-assisted coiling and
stent-assisted coiling different? Morphological analysis of 113
unruptured wide-necked aneurysms treated with adjunctive
devices. Neurosurgery. 2014 Aug;75(2):145-51; quiz 151.
198 J Cerebrovasc Endovasc Neurosurg
13. Raymond J, Guilbert F, Weill A, Georganos SA, Juravsky L,
Lambert A, et al. Long-term angiographic recurrences after se-
lective endovascular treatment of aneurysms with detachable
coils. Stroke. 2003 Jun;34(6):1398-403.
14. Shapiro M, Becske T, Sahlein D, Babb J, Nelson PK. Stent-sup-
ported aneurysm coiling: a literature survey of treatment and
follow-up. AJNR Am J Neuroradiol. 2012 Jan;33(1):159-63.
15. Wang K, Sun Y, Li AM. Peri-procedural morbidity and mor-
tality associated with stent-assisted coiling for intracranial
aneurysms. Interv Neuroradiol. 2013 Mar;19(1):43-8.